Liver Transplantation

Who performed the first human liver transplant?

Thomas E. Starzl, MD, PhD

1963 - his first human attempt
1967 - his first human success
1999 - most cited man in clinical medicine
2004 - awarded National Medal of Science

What is the most common cause of chronic liver disease in a non-alcoholic?

Viral Hepatitis (C>B)

What are the two most common cholestatic diseases requiring transplantation in adults?

#1 - Primary Biliary Cirrhosis
#2 - Primary Sclerosing Cholangitis (70% having IBD)

What is the most common cholestatic disease requiring transplantation in children?

Biliary atresia

What are optimal tumor size criteria for liver transplantation with hepatocellular carcinoma?

Single lesion smaller than 5cm
Less than 3 lesions smaller than 3cm

What is Wilson's Disease?

An autosomal recessive disorder of copper excretion leading to chronic hepatitis and cirrhosis

What is Budd-Chiari Syndrome?

Hepatic vein thrombosis

What are the most common causes of acute / fulminant hepatic failure?

Acetaminophen overdose
Acute Hepatitis B
Drugs
Hepatotoxins
Wilson's Disease

What are indications for Liver Transplantation?

1. Decompensated cirrhosis

Hepatic encephalopathy
Ascites
Spontaneous Bacterial Peritonitis
Portal hypertensive bleeding
Hepatorenal Syndrome
Malnutrition

2. Fulminant Hepatic Failure

What are contraindications to Liver Transplantation?

Disseminated malignancy: HCC c metastatic disease, vascular invasion, or significant tumor burden
Extrahepatic malignancy (defer 2 years p curative treatment)
Infection / Sepsis
Cardiac and pulmonary issues (i.e., pulmonary hypertension)
Ongoing substance abuse

Pretransplantation evaluation must assess for evidence of:

1. Hepatopulmonary syndrome - intrapulmonary AV shunting
2. Pulmonary HTN - associated c high risk of mortality
3. Hepatorenal Syndrome - requires optimization of renal function pretransplant

The Surgical Procedure can be summarized as follows:

I. Pre-anhepatic Phase : Mobilization of the diseased liver

1. Isolation of supra and infrahepatic vena cava
2. Isolation of portal vein
3. Isolation of hepatic artery
4. Division of the bile duct
5. Application of vascular clamps
6. Recipient hepatectomy

II. Anhepatic Phase : Decreased venous return
Some surgeons elect to use venovenous bypass routinely or selectively (CFA and portal vein are cannulated with venous return via thoracic central line)

1. Orthotopic placement of donor liver
2. Suprahepatic caval anastomosis
3. Infrahepatic caval anastomosis
4. Portal vein anastomosis
5. Removal of portal and caval clamps

III. Post-anhepatic Phase : Characterized by marked changes in hemodynamic parameters

1. Hepatic arterial anastomosis
2. Biliary anastomosis - choledochoduodenostomy or choledochojejunostomy

What is the "Piggyback Technique"?

The recipient's IVC is preserved, with an anastomosis between the suprahepatic donor cava to the confluence of the recipient hepatic veins. The benefit is the recipient cava does not have to be completely cross-clamped during the anastomosis.

What are Donor considerations with a Partial Liver Transplant?

Harvest is from either a living-donor or a split-liver deceased donor
Left lateral segment is ideal for pediatric recipients
Right lobe is ideal for adult recipients

Living donors must be screened for medical fitness, anatomy, and psychosocial issues (r/o coercion)

What are the risks to the living donor?

10-15% morbidity
Less than 0.5% mortality

What are common graft survival rates?

85-90% at one year

deceased donor - 64% at five years with 72% patient survival
living donor - 73% at five years with 86% patient survival

What is the incidence of primary nonfunction of hepatic allografts?

3-5%, with a mortality>80% without retransplantation

What is the most common vascular complication after liver transplant?

Hepatic Artery Thrombosis

This can also result in biliary stricture. Rates are 3-5% in adults and 5-10% in children... higher with partial liver transplants.

How frequently does Hepatitis C recur after transplantation?

Recurrence is almost universal. Tx: Ribavirin and IFN-alpha

Hepatitis B recurrence has decreased with use of HepB IgG and lamivudine (= 3TC = Epivir).
Primary sclerosing cholangitis, HCC, and autoimmune hepatitis are also known to recur

What is the Kasai Procedure?

Portoenterostomy for biliary atresia

This is successful in 40-60% of kids, but 75% of children will still require transplantation secondary to cholestasis and cirrhosis

Phew... That's all for now... SG

Source: Schwartz' Principles of Surgery, 8th ed.